MAUDE Adverse Event Report: RANIR LLC PLACKERS; MOUTHGUARD, OVER-THE-COUNTER

Model Number MTH GD GNM 10

Device Problem Use of Device Problem (1670)

Patient Problem Injury (2348)

Event Date 02/04/2017

Event Type  Injury  

Event Description

I swallowed night protector and had to have an endoscopy.

• Brand Name: PLACKERS
• Type of Device: MOUTHGUARD, OVER-THE-COUNTER
• Manufacturer (Section D): RANIR LLC; 4701 east paris ave. se; grand rapids MI 49518
• Manufacturer (Section G): RANIR LLC; 4701 east paris ave. se; grand rapids MI 49518
• Manufacturer Contact: rebekah stenske ; 4701 east paris ave. se; grand rapids, MI 49518 ; 6166988880
• MDR Report Key: 6371880
• MDR Text Key: 68814944
• Report Number: 1825660-2017-00058
• Device Sequence Number: 1
• Product Code: OBR
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K091175
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: consumer
• Reporter Occupation: Device Unattended
• Type of Report: Initial
• Report Date: 02/07/2017

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 03/02/2017
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Device Operator: Device Unattended
• Device Model Number: MTH GD GNM 10
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: No
• Distributor Facility Aware Date: 02/04/2017
• Date Manufacturer Received: 02/04/2017
• Is the Device Single Use?: No
• Type of Device Usage: Unknown
• Patient Sequence Number: 1